Scary to many, but potentially lifesaving

That's what patients ask Dr. Kenneth Chang, chief of gastroenterology at UC Irvine. It explains, he says, why half of those who should undergo endoscopic procedures to screen for cancers of the digestive system don't.

It was the doctor who said it, but I'd thought it, more than a few times.

After decades of heartburn, I was a prime candidate for an upper endoscopy to find out if out-of-control stomach acid had caused serious damage. A flexible tube with a camera would be inserted through the mouth, into the esophagus and down into the stomach and upper part of the small intestine to detect early signs of cancer or precancerous conditions.

As someone who panics when the doctor puts a stick in my mouth and tells me to say “Ahh,” this was scary.

The National Cancer Institute expects nearly 18,000 new esophageal cancer diagnoses in the U.S. this year – about 80 percent of them in men – and more than 15,000 deaths from cancer of the esophagus among men and women combined. The five-year survival rate, as of 2010, ranged from about 3.5 percent for esophageal cancer that has metastasized to 38.6 percent for localized cancer, according to the NCI.

I didn't know those numbers when I deemed the screening optional and rejected the idea.

Unlike the upper endoscopy, the related colonoscopy I underwent two years prior was more of a must-do. I was having digestive issues that weren't easily diagnosed, and doctors strongly encouraged me to have the test. Another what going where. In this case a tube would be going up, not down, to see what was going on in the large intestine. I cringed. And I passed.

But after some calmer thinking, and assurances by those who'd gone before me that the procedure sounded worse than it was – and that I'd be completely knocked out for it – I agreed to the scoping. Terrifying yes, but the anesthesia allowed me to sleep through it.

Not exactly a bucket list item, but the colonoscopy, which showed nothing wrong, could now be checked off the to-do list, at least for 10 years, provided no other symptoms appeared.

And I felt pretty relieved about that. As Dr. John Lee, associate director of the UCI Comprehensive Digestive Disease Center, stressed later, about 150,000 new cases of colorectal cancer are diagnosed annually. With about 50,000 fatalities a year, it is the second-leading cause of cancer deaths among men and women combined, behind only lung cancer.

“Colonoscopies have been shown to save lives by giving us a chance to see precancerous lesions and increasing survival rates,” says Chang, executive director of the H.H. Chao Comprehensive Digestive Disease Center at UCI. “Unfortunately, only 45 to 50 percent of patients who should be screened based on age and other factors get screened. … The predominant barrier is perception and awareness. People may not know that colon cancer is the No. 2 cancer for men and women.”

Turn 50, get a colonoscopy. That's the generally accepted guideline.

“That has been codified by all the medical societies,” Chang says. “The risk of colon cancer and colon polyps is relatively low in your teens and 20s. It starts creeping up in your 30s and 40s. By the time you get into your fifth decade, you're more likely to find polyps and precancer, and that continues to increase in your 60s and 70s. We try to hit the sweet spot with 50, where you're most likely to find a rapid increase in prevalence and still be able to do something about it.”

Public awareness about the importance of screening for colon cancer rose after the husband of journalist Katie Couric died of the disease in 1998, at age 42, and Couric went public, says Dr. Abhay Parikh, a gastroenterologist with the Hoag Endoscopy Center, which opened 21/2 years ago at Hoag Health Center in Newport Beach. And when Medicare began covering routine colonoscopies in April 2011, Parikh says, there was further demand for the tests.

“Cancers of the colon usually come from polyps,” says Parikh. “And we want to remove them to prevent them from turning into cancer.”Things aren't as well-defined when it comes to the esophagus.

“Upper endoscopy is (recommended) if you have abdominal pain, bleeding, can't eat, can't swallow, stuff like that,” Lee says. “The other group of patients where it should be considered is those who have long-standing reflux. We screen for Barrett's esophagus, a precancerous condition related to reflux.”

Barrett's is the formation of something similar to a callous on the esophageal lining, Lee says. Rather than the normal flesh color, an esophagus with Barrett's is salmon pink.

“About 15 percent of patients with chronic acid reflux do have Barrett's,” Parikh says. “For most people, I would say if you're doing fine on medications (proton pump inhibitors such as Prevacid and Prilosec) and don't have to take them all the time, you're probably OK.”

In my case, after a couple of years of putting off the test I set a date. And almost immediately began looking for excuses to cancel it.

I quoted to anyone who would listen the new guidelines for the treatment of GERD (gastroesophogeal reflux disease, a more severe form of acid reflux) released by the American College of Physicians in late 2012. According to the ACP, upper endoscopies are being overprescribed in the U.S. for GERD.

“In general, in this country, there's a feeling that we do too many tests, whether it's X-rays, blood tests, CT scans, what have you,” Lee says. “Does that include endoscopy? Yes.”

Ultimately, for me, it was better safe than sorry. Fact was, despite not being otherwise high-risk – nonsmoker, no family history of esophageal cancer, for instance – my chronic acid reflux put me in harm's way.

Prior to the test I searched online for words of comfort about the probing and found YouTube videos of shrieking patients as they prepared for their upper endoscopies. Not helpful.

What was helpful was the call I received the night before the procedure from Lee, who wanted to know if I had any questions. Turns out I did. Would I have to be conscious for the test? I'd previously been told that doctors would need my help swallowing the tube down my throat. Knowing myself, I knew we'd all regret that.

Lee gave me two options: A dose of a fast-acting sedative – a benzodiazepine – that would put to sleep; or that plus propofol – the anesthetic that knocked me out for my colonoscopy. He pointed out that propofol is more commonly given to younger people who are really scared. I'm not exactly a younger person, but I was a really scared person, so propofol it was.

Nevertheless, I was nervous during prep the next morning, not only about the procedure, but about its cost. Oddly, it wasn't something I'd thought to ask about. And the propofol was an additional expense. The procedure ended up costing $2,895, the anesthesiology an additional $1,703, with my insurance covering the bulk of it. Costs vary based on type of coverage.

Forms filled out and gown put on, I waited for the next step. My vitals were taken and with my blood pressure high they hooked me up to a heart monitor to make sure everything was OK. It was, and we were ready to go.

Perhaps they're overprescribed, but upper endoscopies can prove vital for those who exhibit risk factors.

What it comes down to, he says, is there's a time in life – about age 50, assuming no earlier signs of increased risk – when we need to be especially vigilant about our well-being, however unpleasant some of the details may sound.

“Take charge of your health,” he says. “These procedures are now very, very easy and well-tolerated. Patients almost always report a pleasant, ‘that wasn't so bad' experience, as opposed to ‘that was awful – I'll never do it again.'”